DEATH CLAIM FORM (DCF) CLAIMS DOCUMENT CHECKLIST (CDCL)

Life Assured Name: Policy No.:

Please submit this form along with the requirements mentioned below at the nearest branch or address mentioned overleaf for faster processing of claim Documents from 6 to12 not required in Pension Policies (other than Pension Elite) Please note that all documents needs to be self attested. Claim Document Please tick the documents submitted

1. Original Death Certificate or attested copy thereof issued by Municipal Authorities. 2. Original Policy Document (s). 3. Claim Form duly filled, signed by claimant and duly attested by an authorized person as mentioned in claim form 4. Copy of Claimants current address proof 5. Authorization Form duly filled, signed by claimant 6. Copy of Claimants Photo Id proof which establishes relationship with life assured 7. Copy of signed cancelled cheque (Mandatory) with NEFT Mandate Form 8.Last Medical Attendants Report 9. Copies of all past Medical Records, Diagnostic Test Reports, Discharge/ Death summary 10.Employers questionnaire In case of accidental/ unnatural death, in addition to the above , the following documents are required 11.Copy of First Information Report ( FIR) 12.Copy of Post Mortem Report, Viscera Report 13.Inquest Panchanama 14.Policy Final Investigation Report 15.Newspaper cutting (If any)

Claim/DCF/Ver1.0/1stApr2011

Aviva Life Insurance Company India Ltd. 3nd Floor, Aviva Towers, Sector 43, Opposite DLF Golf Course, Gurgaon - 122 003 Haryana India Tel. +91(0)124 270 9046 Fax +91(0)124 257 1206 www.avivaindia.com Registered Office: 2nd Floor Prakashdeep Building, 7, Tolstoy Marg New Delhi 110001 India

DEATH CLAIM FORM (DCF)

1.Policy No.: 2.Name of Deceased Life Assured:

First Name

Middle Name

Surname

Section I -Details of the Claimant

3.Name of Claimant

First Name Middle Name 4. Current Residential Address (Current Address should match with Address proof provided)

Surname Mobile no.: Phone no. with STD Code:

City:

Pin Code:

Email Id:

5. Relationship with Life Insured 6. Title under which the claim is submitted (Please Tick) 1. Nominee 6. Beneficiary 2. Appointee 7. HUF 3. Survivor 4. Assignee 5. Trustee

7. Bank Account Details: Please find enclosed NEFT Mandate Form Mandatory: (Please attach a copy of signed cancelled cheque along with this form) 8. If there is any other claim underlying the policy, please tick the appropriate box and submit respective claim form for the same.

HCB

Critical Illness

Permanent Total Disability

Section II Details of Deceased Life Insured

Date of Birth

Claim/DCF/Ver1.0/1stApr2011

Date of Death Place o Death Cause of Death If Place of Death is outside India: Yes No

Time of Death

a.m./p.m.

Was the deceased buried or cremated abroad? If yes, enclose a copy of the burial/ cremation permit. Employment Details: Name of the Employers /Business Name

Address :

City & Pin Code : Exact nature of Job/ Business Death due to Accident: Date of Accident Place of Accident

Mobile or Phone no.

Time of Accident

a.m./ p.m.

Please provide duly attested copy of documents mentioned in the checklist for accidental death (From 8 to 12)(Mandatory) Death due to Illness: Date of First Complaint of Symptoms Name of the Doctor/ Hospital or Clinic who declared death Name of the Doctor/ Hospital or Clinic consulted during last illness Address, Contact No Date of Consultation Nature of Illness

Name of the Doctor/Hospital who was consulted for present illness or any other illness during the last three years. Name of the Doctor/ Address, Contact No Date of Nature of Illness Hospital or Clinic Consultation

Claim/DCF/Ver1.0/1stApr2011

Sum Assured Policy no.

Name of Insurance Company

Date of Commencement

Claim Status

Rider Coverage (if any)

Declaration: In connection with claim under policy no. on the life of Life Insured , I hereby declare that the statement made herein above I true in each and every respect. for Rs. Claimant, do

*Countersigned By: Date Designation Address

Signature of the Claimant: Date Address

Certified that the contents of this form were explained to the declarant in vernacular and he/she has affixed is/ her signature/ thumb impression hereto after fully understanding the same. Signature Name of the Witness: Designation: Address:

* This statement must be countersigned by any of the following: (1) an Advocate (2) A Bank Manager (3) A Medical Practitioner (4) A Gazette Officer (5) A Head Master/ Principal of a local Govt. High School (6) A magistrate (7) President Of A Village Panchayat or Local Board (8) Sales Manager of Aviva Life Insurance Company India Limited

Claim/DCF/Ver1.0/1stApr2011

AUTHORISATION
(To be filled & signed by the Claimant) Life Insurance Policy No.(s) ____________________________________ I, Mr. / Mrs / Ms. ______________________________________ (name of the claimant), _______________________________________________ (relation with Life Assured) hereby give my consent to M/s Aviva Life Insurance Company India Limited, and / or its representative to obtain all employment / medical / hospital records / police records / other records (including photocopies) / information pertaining to the treatment / occupation of the deceased Life Assured which he/ they may have acquired whether before or after the policy as well as details from other Life Insurance Companies regarding any existing policies which he / they may have sourced before or after the initiation of this contract. Date: Place: (Signature of Claimant) Contact details of the claimant: Address: ________________________ ________________________ ________________________ ________________________ Pin: ____________________ Landline: STD Code _______ No. _______________ Mobile: __________________ Email id: .. Yours faithfully

Claim/DCF/Ver1.0/1stApr2011

NEFT Mandate Form: Direct Transfer of Claim amount to your Bank Account
Mandatory: Copy of cancelled cheque bearing the below mentioned account number along with this form .
To, AVIVA life Insurance Company India Limited, Sub: E-Payments vide NEFT I/We request and authorize you to effect E-payment vide NEFT mode to my/our Bank account as per the details given below: Full name of the Claimant:
First Name Middle Name Surname

Full name of the Bank Account Holder as appearing in the Account:

First Name Middle Name Surname

Bank Account No.

Bank Name: Bank Address ( Including State, City, Pin Code):

Bank Branch contact persons names and Tele nos with STD Code: Account Type: Saving Account Current Account

Bank Branch IFSC Code No. ( Mandatory for NEFT): Bank Branch MICR Code: I/We confirm that information provided above is correct and any consequences due to any mistake in above will be borne by me. Thanking You, Name & Signature of the Claimant:

Bank Verification:
We confirm that we are enabled for receiving for NEFT credits and we further confirm that the account number of the and the signature of the authorised signatory and the IFSC and MICR codes of our branch mentioned above are correct. Bank verification Stamp with branch address and Signature of the Banker Name of the Signing authority

Claim/DCF/Ver1.0/1stApr2011

ACKNOWLEDGEMENT SLIP

Policy No.:
Name of Life Assured .. Service Request ID:... Documents Submitted: Please Tick Attested Death Claim Form and Signed by the Claimant Original Death Certificate or attested copy thereof issued by Municipal Authorities Original Policy Document (s) Copy of Claimants current address proof Copy of Claimants Photo Id proof which establishes relationship with life assured Copy of signed cancelled cheque (Mandatory) with NEFT Mandate Form Last Medical Attendant Report Medical Records Employers Questionnaire Copy of First Information Report (FIR) Copy of Post Mortem Report, Viscera Report Inquest Panchanama Policy Final Investigation Report Newspaper Cutting

BRANCH STAMP WITH RECEIPT DATE:

Claim Contact Points Mailing Address:

Processed by (Name & Signature):

For any urgent queries contact:

For any Claim related queries please write to:

Aviva Life Insurance Company India Ltd. rd 3 Floor. Aviva Towers, Sector-43, Opposite DLF Golf Course, Gurgaon-122003 Haryana

Customer service Helpline Number 1800-180-22-66 (Toll Free) 0124-2709046

claims@avivaindia.com

Claim/DCF/Ver1.0/1stApr2011